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traumatic dental injuries CE article | 21 roots 4 2016 prior to obturation is recommended; however, one should allow the PDL to heal for two weeks before placement(seetreatmentforavulsion,below).Apexi- ficationorrevascularizationisrecommendedforteeth with open apices.24, 25 It is important to remember that dental injuries do not always fall into one group or category, but often acombinationofseveralcategories.Injuriesinmulti- ple categories will impact the outcome. For example, it was recently demonstrated that the existence of a concurrent luxation injury with an uncomplicated crown fracture and complete root development are significant risk factors of pulp necrosis.26 Avulsion The time outside of the socket for an avulsed tooth is the most critical of its survival. If the tooth is re- planted within 30 minutes, or alternatively kept in a physiologicalsolutionofspecializedmediaormilkfor a few hours, it has a fairly good prognosis.27, 28 If the tooth has been dry for more than one hour, the peri- odontal ligament cannot be expected to survive and the tooth will likely become ankylosed (Fig. 7). Once reimplanted, most teeth need to be stabilized with a physiological splint for two weeks.29 If the avulsed tooth has an open apex and was re- implanted within the hour, there is a possibility that the pulp will revascularize. In this case, delaying end- odontic treatment at the emergency stage is recom- mended. Endodontic treatment should be performed later only if signs of pulpal necrosis, root resorption and/or arrested root development are confirmed. Inthecaseofaclosedapex,revascularizationisnot expected. Therefore, endodontic treatment must be initiated two weeks after the tooth is reimplanted, and prior to removal of the splint. Treatment should not be initiated earlier because any further manipu- lationofthetoothpriortoorimmediatelyafterreim- plantation can cause further damage to the PDL. In addition, it has been shown that placing calcium hy- droxideasanintracanalmedicamentimmediatelyaf- ter reimplantation will promote inflammation that can lead to PDL damage.30 If the tooth had been kept dry longer than 60 minutes, performing root canal treatment prior to replantation is indicated.31 After the emergency situation has been managed and the tooth/teeth stabilized, the second phase be- gins, in which the pulpal condition and likelihood of rootresorptionhavetobecarefullyevaluatedandthe patientfollowedoveraperiodofmonths,ifnotyears. Afollow-uptimelineisessentialtoallowforinterven- tion if signs of complications appear. In such cases, the expertise and training of endodontists become important. Diagnosing, preventing and treating any pulpalcomplicationsareanintegralpartofendodon- tic training as are performing pulp regenerative pro- cedures and treating inflammatory root resorption (Figs. 8a & b). Conclusion Traumatic dental injuries present difficult chal- lenges for both patients and their dentists. Current evidence allows the dental health care provider to manage situations that, in the past, often resulted in crippled dentition and unsightly appearance. Appro- priate treatment can turn what at first glance looks like a hopeless situation into a very satisfactory out- come for patients. The endodontic specialist can play an important role in the team approach to treating patients with traumatic dental injuries._ Editorial note: Reprinted with permission from the Ameri- can Association of Endodontists, ©2014. The AAE clinical newsletterisavailableatwww.aae.org/colleagues. Acompletelistofreferencesisavailablefromthepublisher. author DrAsgeirSigurdsson,DDS,MS,wasbornandraisedinReykjavik, Iceland.HereceivedadentaldegreefromUniversityofIceland,Faculty ofDentistry,in1988.AfteroneyearinprivatepracticeinIceland,he movedtoChapelHill,NC.HegraduatedfromUniversityofNorth Carolina(UNC)atChapelHillin1992withacertificateinendodontics andamasterofsciencewithemphasisonneurobiologyandpain perception.Hewasafull-timefacultymemberatUNCSchoolof Dentistryfrom1992until2004,firstasanassistantprofessorandthen associateprofessorwithtenurebeginningin2000.Hewasappointedasthegraduateprogram directorofendodontics(specialtytraining)in1997andservedinthatpositionuntil2004.From 2004to2012hewasinaprivateendodonticpracticeinReykjavik,Iceland,andLondon,England. InSeptember2012hebecamethechairmanofthedepartmentofendodonticsatNewYork UniversityCollegeofDentistry.Additionally,heholdsthefollowingacademicpositions:From2004 adjunctassociateprofessoratUNC;honoraryclinicalteacherinendodontology,UCLEastman DentalInstitute,London,from2006;andfrom2011honoraryclinicalassociateprofessorinthe FacultyofDentistry,theUniversityofHongKong.Hehaslecturedextensivelyaroundtheworldon dentaltrauma,endodontics,paindiagnosisandforensicdentistry. HeisactiveinmanyprofessionalorganizationsandispastpresidentoftheInternational AssociationforDentalTraumatology(IADT).HereceivedtheEdwardM.OsetekEducatorAward fromtheAmericanAssociationofEndodontistsin1998. Fig.7:Ankylosis or replacement root resorption,in which the root structure is lost and replaced by bone.Note that no apparent PDL space is seen. Fig.8a: Inflammatory root resorption secondary to pulpal necrosis and infection in the pulpal space after avulsion.If diagnosed in time,it is possible to arrest the root resorption and maintain the tooth.Extensive inflammatory root resorption on a tooth that was avulsed and reimplanted,but nofurthertreatmentdoneforsixweeks. Fig.8b: Calcium hydroxide was placed in the tooth for three months.Apparent healing of the peri-root lesions and some reconstitution of a normal looking PDL. Fig.7 Fig.8a Fig.8b 42016